Thoughts on Choosing Wisely and Overuse
About five months ago nine physician specialty groups got together and decided to examine specific tests and procedures that are commonly used but not necessary in their respective fields. They named their organization “Choosing Wisely”, and compiled a list of over 45 specific recommendations on practices that should be curtailed. Examples included “lumbar series in low back pain”, “CT scan in non traumatic syncope” and many others.
I thought this was a bold first step on beginning the conversation on how we as providers can reduce the waste in our health care system and start thinking about appropriately delivering care when we have finite resources. Studies estimate that almost $700 billion each year are spent on unnecessary procedures, tests and end of life care. Not only is this overuse unnecessary, but it delivers no improvement on the quality of care. Increased testing may actually increase risk to patients with unsafe procedures, radiation, medication side effects and spurious lab findings that trigger even more testing.
Of course, naysayers will always point to medical liability as a roadblock to changing our practice patterns. I call that a cop out. Surely there are things we can identify that we can do that carry no further medicolegal risk and provide safe quality of care. Are the coags that are being ordered on the non-anticoagulated patient with chest pain really helping save you from the lawyers? Is the amylase that is routinely ordered for abdominal pain offering you that much protection from the courts? I can go on and on, but the point is that we as health care providers must take control of our health care system and not allow others to make these decisions for us.
It’s also important to note that the initiative is not about “rationing” health care, but delivering health care in a more “rational” manner. It’s about assisting providers in providing appropriate health care rather than limiting access to health care. It’s about preventing the harm and duplication of procedures and encouraging providers to acknowledge that health care not supported by evidence is truly not necessary.
I found it somewhat disheartening that our own specialty organization ACEP chose to not join in the Choosing Wisely fight, citing liability and the unique environment of the ED as primary concerns. Hopefully that will change in the future, as this initiative picks up more momentum.
For now, I am excited that we are beginning the discussion on one of the most serious crises in American medicine – overuse.
- Vipul Kella, MD